This audit is relevant to psychiatrists working in child and adolescent mental health services (CAMHS). It is most suited to out-patient settings.
Depression has been dealt with in a variety of different ways in CAMHS. It is important to examine what happens in practice, and to monitor this regularly, according to best-practice guidelines. A 2005 guideline produced by the National Institute for Health and Clinical Excellence (NICE) attempted to standardise the approach to depression in terms of assessment and treatment according to the evidence base. More recent evidence, however, called some of those recommendations into question, including using medication as a second-line treatment for moderate to severe depression (Goodyer et al, 2007). However, several parts of the guideline are sound and can provide a useful benchmark for best practice in the areas of assessment and treatment.
ᐅ The diagnosis of depression is clearly communicated in the letter to the referrer.
ᐅ Clinical notes contain the following information from assessment:
▹ comorbid conditions
▹ family context
▹ school context
▹ peer relationships.
Psychological treatment standards
ᐅ A relevant evidence-based treatment modality (e.g. cognitive–behavioural therapy or interpersonal psychotherapy) is clearly documented.
ᐅ Psychological treatment is reviewed regularly.
Medication treatment standards
ᐅ Fluoxetine is chosen as the first-line medication for depression.
ᐅ Medication is monitored regularly (at least monthly in the first 3 months).
ᐅ There is clear documentation of discussion of the risks and benefits.
The target is that all of the above standards are met.
Cases that had been coded on the CAMHS database as moderate or severe depressive disorder were collected. Information was obtained from the following sources: the assessment letter and subsequent letters for the first 3 months, including multidisciplinary review sheets.
The percentage of patients coded with a moderate or severe depressive disorder for whom the above standards were met was calculated.
Data collection could be carried out by staff at multidisciplinary team meetings. A coordinator is needed to plan the data collection sessions, to design the pro formas and to analyse the data.